Last week, I took note of how what is now a major medical society devoted to integrative oncology, the Society for Integrative Oncology (SIO), revealed itself to be unable to define, other than in platitudes and vague feel-good verbiage, just what the heck “integrative oncology” even is when it published a monograph in JNCI. What I didn’t take note of last week was that the November issue in which the SIO’s monograph defining what integrative oncology is (or what the SIO thinks it is) didn’t contain just that one gem. In fact, like previous monographs published in years past, it’s chock full of SIO propaganda for integrative oncology. Indeed, there’s so much there that I could easily spend the next few weeks writing about each monograph in turn. I won’t do that today, although I do reserve the right to discuss one or two more over the next couple of months if the urge takes me. What I do want to do is to discuss one monograph in particular, “Growth of Integrative Medicine at Leading Cancer Centers Between 2009 and 2016: A Systematic Analysis of NCI-Designated Comprehensive Cancer Center Websites,” by Hyeongjun Yun, Lingyun Sun, and Jun J. Mao. I note that Dr. Mao is the immediate past president of SIO; this is coming from the top, so to speak.
I noted last week that I’m not a fan of the SIO, and it’s not a fan of me. I won’t repeat the story of my little discussion with them in which, in response to its umbrage taken in reaction to an article I published three years ago about integrative oncology, I tried to educate the leadership of the SIO that you can’t have naturopathy without homeopathy. Reread last week’s post if you want the details. My point is more that, as much as I don’t like what SIO stands for, it has, unfortunately, been effective, and this survey provides yet another metric suggesting its effectiveness, along with that of all the other groups promoting the integration of pseudoscience and mysticism into medicine.
“Unmet needs”? Why would one need pseudoscience?
Yun et al. justify this survey with the usual tired tropes used to justify “integrating” quackery with medicine, be it oncology or any other specialty. First, frame integrative oncology as an “unmet need”:
Patients’ unmet needs in managing these symptoms coupled with their desire to use natural approaches to improve their health have created a demand for integrative medicine (3,4). According to the National Center for Complementary and Integrative Health (NCCIH), integrative medicine differs from complementary and alternative medicine (CAM) because it brings together conventional and complementary treatments in a coordinated way (5). Neither rejecting conventional therapies nor relying on alternative medicine, integrative medicine adopts only those complementary modalities supported by the highest evidence of safety and effectiveness (6). Numerous studies have evaluated the efficacy of utilizing integrative medicine modalities to treat the side effects of conventional cancer therapies. For instance, there is growing evidence that acupuncture may be effective in managing cancer therapy–related adverse effects such as fatigue (7–10), postoperative pain (11,12), vasomotor symptoms (13–16), and nausea and vomiting (17). Likewise, research supports the use of modalities such as massage (18,19) and mind-body therapies for symptom management and spiritual transformation; the latter remains a largely unmet need in the current health care system, yet directly impacts patients’ quality of life (4,20–23).
I can’t help but wonder how one quantitatively evaluates “spiritual transformation” in rigorous clinical trials, but that’s just me. In any case, I can’t help but note that some of the citations are articles discussed here and elsewhere before. For instance, reference 5 has been addressed before as “integrative health” being a rebranding of “complementary and alternative medicine” (CAM), which was a rebranding of alternative medicine. Other references, for instance, the ones supporting acupuncture, cite the usual low quality studies or studies that rebrand transcutaneous nerve stimulation (TENS) as “electroacupuncture.” Then there’s the whole framing of integrative oncology as an “unmet need.” It’s a very common framing of integrative medicine, be it through taking advantage of the opioid crisis to sell pseudoscience by claiming that nonpharmacologic management of pain must include CAM or by arguing that addressing unmet needs in symptom management in cancer patients requires embracing pseudoscience. True, the latter argument isn’t stated in those words, but when you strip away the “integrative” and CAM gobbledygook, that’s the core of the argument you’re left with: A false dichotomy that posits that, to treat the “whole patient” and to address “unmet needs,” doctors must embrace the quackery in integrative medicine.
Next up, appeal to popularity:
The use of integrative medicine is extensive among cancer survivors. Globally, up to 43% of patients with cancer have used integrative medicine therapies during their treatment, and the overall prevalence of integrative medicine use has increased noticeably over the past years (24–26). In the United States, cancer survivors use integrative medicine even more than individuals without cancer (27). Cancer survivors are more likely to use integrative medicine modalities for wellness, pain, and improving their immune functions. Interestingly, most of them started using integrative medicine because their conventional health providers recommended it to them (28).
Of course, as we’ve discussed before, this percentage is inflated by the broad definition of “integrative medicine.” Basically, if you’ve ever had a massage or done art or music while being treated for cancer, by definition you’ve used integrative medicine. If you’ve ever meditated or prayed while being treated for cancer, you’ve used integrative medicine. If you’ve done Tai Chi, yoga, or Qi Gong (or even just exercise) while being treated for cancer, you’ve used “integrative medicine.” You get the idea. When you look at the “hard core” quackery, such as homeopathy, you’ll usually find that the number of patients using it is in low single digit percentages.
Integrative oncology and NCI-CCCs
The current survey is an update to a 2009 survey that found that 60% of National Cancer Institute (NCI)–designated comprehensive cancer centers (NCI-CCCs) provided information related to integrative therapies on their websites. Back in 2009, there were only 41 NCI-CCCs. Now there are 45. It’s worth looking at the old survey first, though, to see the sorts of modalities that were being offered at NCI-CCCs eight years ago and at what percentage of them:
Specific therapies listed did include some pure faith healing-related “energy medicine” quackery such as reiki (37% of websites), healing touch (29%). Not surprisingly, acupuncture showed up on 59% of websites, and dietary supplements, herbal medicine, and nutrition in one form or another showed up on between 42% and 56% of websites. To be honest, I was actually pleasantly surprised that only 60% of NCI-CCCs provided information on CAM. Indeed, it’s kind of amusing to note the reaction of the authors to the perceived deficiencies of various NCI-CCCs with respect to CAM:
Even with acknowledging these limitations, we still found that almost a third of leading U.S. cancer centers do not have functional websites related to CAM, and only a small proportion of the centers had websites independently judged to be excellent.
My reaction to that conclusion was: Gee, you say that as though it were a bad thing. I’m also happy that my cancer center’s website would almost certainly have been in that one-third of cancer centers without information on CAM. Indeed, one of the things I’ve always liked about my cancer center is the relative paucity of integrative oncology options offered compared to other cancer centers, but I always fear that, sooner or later, we’ll start to try to catch up.
So what’s the situation now? Table 1 in the new study tells the tale. Mentions of quite a few modalities increased sharply. For instance, mentions of acupuncture increased by 30%, from 59% of NCI-CCCs to 89%. That’s right. A whopping nine out of ten NCI-CCCs mention acupuncture credulously, and a full 73% offer it.
As a surrogate for just how much NCI-CCCs have abandoned science when it comes to integrative oncology, I like to examine the most implausible of treatments that fall under the mantle of “CAM” or integrative medicine. For example, mentions of healing touch, which is a form of “energy healing” (that doesn’t actually involve touching) in which the practitioner claims to be able to detect and manipulate a patient’s “life energy” field in order to heal and/or relieve symptoms, increased from 29% to 58%, a doubling of the number, and 29% of NCI-CCCs actually offer this magical, mystical, “healing” touch. Mentions of reiki, which, as I’ve described many times before, is nothing more than faith healing that substitutes Asian mystical religious beliefs for Judeo-Christian beliefs as the basis for healing (replace the “universal source” from which reiki masters claim to derive the healing energy with God or Jesus, and you’ll see what I mean), also increased markedly, from 37% of NCI-CCCs to more than half (53%) of NCI-CCCs, a more than 50% increase. Worse, 40% of NCI-CCCs actually offer reiki.
Not surprisingly, the “soft” parts of integrative medicine, the services that used to be offered for patient support and morale, such as art, music, massage, and various exercise programs but have, thanks to integrative medicine, become medicalized, appear on the vast majority of cancer center websites. One interesting finding is that, while exercise information is provided in 97.8% of cancer center websites, only 56% provide exercise/fitness services for their cancer patients. As much as it irks me that exercise and nutrition have been co-opted by integrative medicine and quacks like naturopaths, both can be science-based modalities for health promotion, particularly in cancer patients, although integrative medicine practitioners, particularly non-MD and non-dietician ones, often implement diet and exercise in non-evidence-based ways. (I’m talking to you, naturopaths, in particular.) Even so, we need to be doing better offering opportunities to help our patients exercise to improve their health and alleviate, for example, chemotherapy symptoms.
Overall, though, the authors are relatively happy with what they’ve found:
Despite these limitations, we found that there has been substantial growth in the presence of integrative medicine on the websites of NCI-designated comprehensive cancer centers since 2009. In addition, the majority of the centers provide integrative medicine services within the same academic health systems in which they are located. As these centers lead the way in cancer research and clinical innovation, we need to ensure that integrative medicine can be cohesively incorporated into the continuum of cancer treatment and survivorship care using a financially sustainable structure. In addition, evidence-informed integrative medicine needs to expand beyond the walls of academic medical centers into community cancer centers and clinics to benefit patients from diverse socio-economic backgrounds.
The SIO even includes plans for world domination (OK, I mean the promotion of integrative oncology) around the world.
What the SIO left out: Most of the quackery
It’s at this point that I can’t resist mentioning what the SIO clearly left out. Remember, as I’ve pointed out many times, the SIO admits naturopaths. So where is naturopathy in this survey? Isn’t naturopathy a part of “integrative oncology”? Certainly, the SIO seems to think so, given that it included presentations on naturopathic interventions in its recent annual meeting and even encourages naturopaths to join, listing them as equivalent to MDs. The SIO has even elevated two of them to the presidency of the organization! So why doesn’t the SIO include a survey of which NCI-CCCs mention and offer naturopathy to their patients? Are they embarrassed? Trying to hide something? One wonders what Suzanna Zick, who was SIO President from 2015-2016, or Heather Greenlee, who was president from 2014-2015, think of this omission? Both are naturopaths.
I really can’t help but suspect that, in its effort to persuade medical academia that integrative oncology is rigorously science- and evidence-based, whether intentionally or not, the SIO leadership is focusing all its attention on promoting the evidence-based modalities that have been “rebranded” as “integrative,” such as diet, exercise, and the like, and the patient support modalities that have been medicalized into “integrative medicine,” such as massage, art therapy, music therapy, and the like. Pay no attention to that quackery that integrative oncology and medicine lump together with the diet, exercise, and the like, the SIO seems to be saying by the absence of focus on naturopathy (and the homeopathy that nearly all naturopaths practice). Again, it can’t be emphasized enough that, wherever you find naturopaths practicing, you will find homeopathy being practiced.
True, there are a couple of exceptions. The SIO does mention reiki and therapeutic touch rather prominently in both surveys, both of which are obvious energy healing quackery. However, most people don’t realize that. Most people view reiki and healing touch as a form of massage or hands-on healing, even though healing touch usually doesn’t involve actually touching the patient. Either that, or they view them as some form of spirituality, which is actually not too far from the truth, but mystical claims such as what are made for reiki and healing touch do not belong in science- and evidence-based medicine. Yet there are NCI-CCCs that credulously promote energy healing. For instance, I’ve written about Georgetown University before. There’s an NCI-CCC there, the Georgetown Lombardi Comprehensive Cancer Center. I’ve described Georgetown as a bastion of quackademic medicine before because of its “pioneering” efforts to “integrate” the teaching of pseudoscience into its medical school curriculum. Relevant to cancer, though, Georgetown published an article in its official magazine about reiki in the chemotherapy suite:
For a long time Denise von Hengst had a secret she kept from friends and physicians alike. As she was undergoing treatment at Georgetown Lombardi Comprehensive Cancer Center for a particularly aggressive type of breast cancer—triple positive, HER2 positive—she was also regularly receiving Reiki, an ancient form of Japanese healing, to mitigate the debilitating anxiety and fear that accompanied her cancer diagnosis.
“At first I told no one about the Reiki,” says von Hengst. “Fear of the ‘woo-woo’ factor. People might think I’m nuts.”
No, I don’t think the patient is nuts. I think the cancer center is irresponsible for offering magic with its medicine, leavened with pseudo-skepticism:
However, skepticism remains, not only in the general population, but also within the medical field. Recently, several clinical trials have emerged attempting to prove, or disprove, the effectiveness of Reiki. Many of these studies have been criticized for the trial. design, number of participants and reporting mechanisms. Results of the trials are often inconclusive.
Yet as the anecdotal proof mounts and Reiki’s popularity increases, prestigious medical centers around the country are taking note and offering the treatment to patients at their facilities. Reiki can be found at hospitals and medical centers such as Boston Children’s Hospital, Dana Farber Cancer Institute, Stanford Health Care, Memorial Sloan Kettering Cancer Center, Duke University Health System and Cleveland Clinic, to name a few. Many academic medical centers such as Georgetown incorporate complementary therapies into their teaching curricula.
I have a question for the leadership of SIO: Is reiki evidence-based? Is it science-based? If it isn’t, then why are you supportive of NCI-CCCs offering it?
Here’s another example, the University of Arizona Cancer Center, which is an NCI-CCC. Take a look at its integrative medicine page. Look at what it offers: reiki (of course, even though a faculty member complained about it), reflexology (pure quackery that posits a nonexistent link between body parts and organs and specific areas on the soles of the feet and palms of the hands), craniosacral massage (which Mark Crislip drolly and correctly called a “SCAM of infinite jest“), healing touch (of course), and shiatsu (unproven).
Three years ago, the son of a professor in a humanities department at UA was treated for leukemia at the UA Cancer Center. He was appalled at all the quackery being offered to his son, including not just the above modalities, but distance healing, offered by a man named Frank Schuster:
Yes, as fantastic as it sounds, this was a web page hosted by the University of Arizona Cancer Center. It might be gone now, but it’s not at all clear that the quack above is gone from UACC.
After this professor complained, Shuster’s UA webpage was either removed or placed behind a login. However, I noticed something about UA’s list of offerings for integrative medicine. First, none of the practitioners were listed by their full names any more. It’s Jessica, Barb, Heidi, Michael, Denise, or Frank, the last of whom offers the reiki classes. Hmmm. I wonder if that’s Frank Schuster, still there, still practicing energy healing. I bet it is, but haven’t been able to verify it one way or the other.
I want to believe that the SIO wants to be scientifically rigorous. I really do. I’m guessing that most of the SIO physician and scientific leadership believes that they are being scientifically rigorous and trying to lay down a framework in science and clinical evidence for “integrative oncology,” even if they have a hard time defining what, exactly, integrative oncology is. It’s just that, for whatever reason, physicians who drink the Kool Aid of integrative medicine tend to develop massive blindspots about all the quackery that comes as a package with all the parts of integrative medicine that they like, such as the emphasis on lifestyle, diet, exercise, and the treatment of the “whole” person. These blindspots extend to naturopathy in particular, which is a veritable cornucopia of quackery, including homeopathy. Until the SIO can eliminate its blindspots over all the quackery that is included in “integrative medicine,” its claims of being scientifically rigorous are just so much self-delusion.